Adjuvant vinblastine, actinomycin D, bleomycin, cyclophosphamide and cis-platinum chemotherapy regimen with and without maintenance in patients with resected stage IIB testis cancer

[Treatment of testicular cancer]

Germ-cell tumours (GCTs) are the most common type of cancer in young men. Since the late 1970s, disseminated GCT have been a paradigm for curable metastatic cancer and metastatic GCTs are highly curable with cisplatin-based chemotherapy followed by surgical resection of residual masses. Patients' prognosis is currently assessed using the International Germ-Cell Consensus Classification (IGCCC) and used to adapt the burden of chemotherapy. Approximately 20% of patients still do not achieve cure after first-line cisplatin-based chemotherapy, and need salvage chemotherapy (high dose or standard dose chemotherapy). Clinical stage I testicular cancer is the most common presentation and different strategies are proposed: adjuvant therapies, surgery or surveillance. During the last three decades, clinical trials and strong international collaborations lead to the development of a consensus in the management of GCTs.

Adjuvant Chemotherapy for Stage II Nonseminomatous Germ Cell Tumors

Management options for patients who have stage II nonseminomatous germ cell cancer, completely resected at retroperitoneal lymph node dissection (RPLND), include two cycles of adjuvant cisplatin-based chemotherapy or close surveillance, with chemotherapy reserved for patients who relapse. Both options are associated with cure in an equally high percentage of patients. The choice of options is influenced by the extent of the tumor resected and patient compliance. Surveillance is a strong consideration for patients who have low-volume nodal disease at RPLND because the relapse proportion is 30% or less. In contrast, patients who have high-volume nodal involvement at RPLND have a relapse rate of 50% to 90% with surveillance alone, and adjuvant chemotherapy is the preferable option in this group.

Relapse-Free and Overall Survival in Patients With Pathologic Stage II Nonseminomatous Germ Cell Cancer Treated With Etoposide and Cisplatin Adjuvant Chemotherapy

Purpose

To assess the long-term relapse-free survival and overall survival of patients with stage II nonseminomatous germ cell tumor (NSGCT) who received two cycles of adjuvant etoposide and cisplatin (EP) after primary retroperitoneal lymph node dissection.

Patients and Methods

Eighty-seven patients with completely resected pathologic stage II NSGCT were treated with adjuvant EP chemotherapy. Adjuvant EP consisted of two cycles of etoposide (100 mg/m2) plus cisplatin (20 mg/m2) per day, administered days 1 to 5 at a 21-day interval.

Results

Ten patients (11%) had pN1 disease, 73 (84%) had pN2 disease, and four (5%) had pN3 disease. Eighty-six patients received two cycles of EP, and one patient received an additional two cycles of EP after a transient marker increase after his first cycle. Eighty-seven patients are alive, and 86 patients (99%) remain relapse-free at a median follow-up of 8 years (range, 0.9 to 13.5 years).

Conclusion

Two cycles of adjuvant EP is highly effective in preventing relapse in patients with pathologic stage II pN1 and pN2 NSGCT. An alternative treatment strategy is surveillance with full-course chemotherapy at relapse. Because there is a higher risk of relapse for patients with pN2 disease, these patients are offered adjuvant chemotherapy.

Predictive factors for the histologic nature of residual tumor mass after chemotherapy in patients with advanced testicular cancer

OBJECTIVES

To further improve the accuracy of the prediction of histologic findings in the residual mass after chemotherapy in patients with metastatic germ cell tumors, various predictive factors were investigated.

METHODS

A total of 23 patients with advanced testicular cancer underwent combination chemotherapy based on cisplatin following surgical removal of residual tumor mass in 20 patients and observation in 3.

RESULTS

Complete fibrosis and/or necrosis was found in 6 (30%) operative specimens, teratoma in 3 (15%), and viable malignant tumor in 11 (55%). Three patients had no evidence of disease for a mean follow-up of 45 months. Five of the 6 patients and all of the 11 patients' results could be predicted by a combination of 4 factors, including absence of teratomatous element in the primary tumor, greater than 85% tumor reduction rate after chemotherapy, normal alpha-fetoprotein and beta-subunit of human chorionic gonadotropin levels after chemotherapy, and actual half-life of alpha-fetoprotein less than 7 days. Among these factors the tumor reduction rate and the actual half-life of alpha-fetoprotein were the most important predictions statistically on multivariate analysis. With the use of these criteria, the sensitivity rate, specificity rate, and overall predictive value of diagnosis for existence of viable malignant tumors were 83.3%, 100%, and 94.1%, respectively.

CONCLUSIONS

By determining these factors it seems possible to avoid surgical removal of the postchemotherapy residual mass in approximately 30% of patients with advanced metastatic testicular cancer.

Intracardiac teratoma 15 years after treatment of a nonseminomatous germ cell tumor

A patient presented to our center with a 15-year history of medical, surgical and radiation treatment for a nonseminomatous germ cell tumor and contralateral seminoma. He experienced a cerebral infarction, which led to the diagnosis of an intracardiac tumor. The tumor was resected and found to be a mature teratoma. We discuss the diagnosis and management of this unusual metastatic nonseminomatous germ cell cancer.

Primary chemotherapy in the management of low stage (IIA and IIB) non-seminomatous germ cell testicular tumours

In a prospective study a total of 65 patients in clinical stages IIA and IIB nonseminomatous testicular tumours were treated by primary chemotherapy followed by retroperitoneal lymphadenectomy in cases with residual disease. The patients were given a combination of cisplatin, vinblastine and bleomycin, or also etoposide. Sixty-two patients (95.4%) achieved complete response: 39 (60%) by chemotherapy alone and 23 (35.4%) following surgical removal of residual disease. Three patients died; there were two drug-related deaths during PVB chemotherapy, one patient had progression of disease following chemotherapy and died as a result of disease dissemination. Three patients relapsed from complete response following chemotherapy, two of them died within 19 and 29 months after the onset of therapy. The third patient received second-line chemotherapy and gained complete response again. Of the 65 patients, 60 (92.3%) survive with no evidence of disease. The follow-up period ranged from 6 to 79 months (mean 39.4 months, median 39 months).

Embryonal carcinoma of the testis

Long-term survival rates were correlated with selected clinical features in 479 patients with embryonal carcinoma of the testis and 33 patients with endodermal sinus tumor (infantile embryonal carcinoma, yolk sac tumor). In the period 1977 to 1982 embryonal carcinoma accounted for 26.8% of newly diagnosed germ cell tumors and 43% of nonseminomatous germ cell tumors entered in the Centralized Cancer Patient Data System. Among patients with embryonal carcinoma, over 80% were diagnosed in the 15-to-34 year age group. Seventy-four percent of the patients had metastatic disease at the time of diagnosis, and 50% of these had distant metastases, attesting to the aggressiveness of embryonal carcinoma and its tendency to early hematogenous spread. Despite the highly malignant nature of the tumor, the overall 5-year survival rate with treatments used was an excellent, 88%. Survival was correlated with the extent of disease at the time of diagnosis; the 5-year actuarial survival rates for patients with localized, regional, and distant disease were 98%, 96%, and 74%, respectively. Endodermal sinus tumor was uncommon (1.8% of all testicular germ cell tumors), occurred predominantly in the younger age group (0-24 years), and in 50% of the cases was localized to the testis. The survival rate for the 33 patients with this form of tumor was slightly worse than for the "adult form" of embryonal carcinoma. The authors conclude that survival of patients with embryonal carcinoma has greatly improved over the last decade as a result of improved methods for early detection of metastatic deposits and the effectiveness of newer chemotherapies in the treatment of disseminated disease.

Adjuvant chemotherapy of solid tumors

Adjuvant chemotherapy for microscopic disease following eradication of clinically detectable lesions by primary surgery and/or radiotherapy is of documented benefit for some oncology patients. However, for many primary cancers efficacy is limited to specific subgroups of patients or has demonstrated no advantage over primary therapy alone. The rationale for adjuvant chemotherapy and results of selected trials are reviewed. In patients for whom adjuvant therapy is of demonstrated benefit, further trials aimed at delineation of patient selection factors, optimal chemotherapy regimens and schedules, and duration of therapy are needed; progress in adjuvant treatment of other subgroups may require development of more effective antineoplastic drugs, in addition to exploration of these factors.

Surgical treatment of patients with stages I and II nonseminomatous testicular cancer

We analyzed treatment outcomes for 98 consecutive patients who underwent retroperitoneal lymphadenectomy for nonseminomatous germ cell testicular cancer between 1972 and early 1979. There were no surgical deaths. Major and minor complications occurred in 8 and 15 patients, respectively. Of the 57 patients with pathological stage I tumors 9 (16 per cent) had recurrences and were given chemotherapy, and all 57 are well 2 or more years after completion of treatment. Of the 12 patients with stage IIA disease who received no adjuvant treatment 5 had relapse, 2 of whom died. Relapse occurred in 13 of 14 patients with stage IIB disease who received no adjuvant treatment and 2 of 4 who received adjuvant radiation. All 3 patients with stage IIC tumor who received no adjuvant treatment had relapse. In contrast, none of the 7 patients with stage II disease who received adjuvant vinblastine and bleomycin with or without cisplatin had relapse. Our long-term survival rates are 100 per cent for patients with stage I and 88 per cent with stage II disease, and all of the patients who died either were treated before the introduction of cisplatin-based chemotherapy or did not complete the treatment protocol as recommended. In experienced hands retroperitoneal lymphadenectomy with chemotherapy, either as adjuvant or as needed for patients with stage I, IIA and IIB disease, remains the most cost-effective treatment for nonseminomatous testicular cancer and has the least short-term and long-term morbidity.

Changing concepts in the treatment of nonseminomatous germ cell tumors of the testis

The development of effective chemotherapy for advanced nonseminomatous germ cell tumors of the testis has changed dramatically the outlook for this once uniformly fatal disease. We reviewed our experience with changing modalities of therapy during a 7-year period in the treatment of 152 patients with all stages of testis tumor. Survival rates have increased from 84 per cent for patients with stage A, B1 or B2 tumors treated with sandwich irradiation therapy and retroperitoneal lymph node dissection to 100 per cent for patients with node dissection with or without chemotherapy. Survival rates continuously free of disease for patients with advanced (stage B3 or C) disease have increased from 53 per cent in 1975 to 1977 to 82 per cent by the addition of platinum-based polychemotherapy and judicious lymphadenectomy. A unified plan of management for patients with low stage and advanced stage nonseminomatous testicular tumors has evolved.

A contribution to the treatment of non-seminomatous testicular tumours

Experiences obtained in the treatment of non-seminomas in 86 men are evaluated. In 71 patients retroperitoneal lymphadenectomy was performed, in 15 also nephrectomy; in 84 men chemotherapy was used. The initial combination consisted of Vincristin, Bleomycin and cis-platin, the maintenance chemotherapy of Vincristin, Methotrexate and Leukeran (chlorambucil). Maintenance chemotherapy was also used in clinical stage N 0 M 0 and in 31 men at this stage no relapse occurred.

No adjuvant chemotherapy in selected patients with pathologic stage II nonseminomatous germ cell tumors of the testis

In a previous report on patients with resected stage II nonseminomatous germinal cell testis tumors the findings of retroperitoneal metastases larger than 5 cm., macroscopic extranodal spread and tumor invasion into retroperitoneal veins (pathologic stage IIC) almost invariably were associated with relapse and poor survival in the absence of adjuvant chemotherapy, while postoperative cisplatin, vinblastine and bleomycin therapy was effective in preventing relapses in all cases. From February 1980 to January 1982, 40 consecutive patients underwent retroperitoneal lymphadenectomy for stage II disease. Only patients with pathologically assessed stage IIC cancer received 4 cycles of adjuvant cisplatin, vinblastine and bleomycin, while those with pathologic stages IIA and IIB disease, with or without microscopic extracapsular extension of the tumor, received no further therapy and were followed carefully at monthly intervals. After a median followup of 26 months or more relapses were noted in none of the 14 treated patients compared to 9 of 26 untreated patients (35 per cent). Of the latter 9 patients 8 (89 per cent) had continuous complete remission after salvage therapy and 39 of 40 patients (97.5 per cent) currently are free of disease. No difference was observed in the relapse rate and survival between patients with stages IIA and IIB disease. We conclude that patients with pathologic stages IIA and IIB disease can be treated safely only at the time of relapse, while the usefulness of adjuvant chemotherapy has been confirmed in those with stage IIC cancer.

Retroperitoneal lymphadenectomy and aggressive chemotherapy in nonbulky clinical Stage II nonseminomatous germinal testis tumors

In a former series of 60 resected Stage II nonseminomatous germinal testis tumors the authors succeeded in demonstrating that adjuvant cisplatin, vinblastine, and bleomycin (PVB) was able to significantly improve survival (100% in 11 treated versus 28.5% in 7 historical controls, P less than 0.01) only in patients with retroperitoneal metastases greater than 5 cm, macroscopic extranodal spread, tumor invasion into retroperitoneal veins (pathologic Stage II-C). Forty-eight evaluable patients with clinical nonbulky Stage II nonseminomatous testis cancer underwent retroperitoneal lymphadenectomy as primary treatment. Four courses of postoperative PVB were administered only to 18 clinically understaged patients (14 pathologic Stage II-C, and 4 postoperatively reclassified as Stage III). The remaining 30 patients were followed at monthly intervals. After a median follow-up of 25 months, relapses were: 1 (10%) in 10 pathologic Stage I patients; 8 (40%) in 20 pathologic Stage II-A and II-B; null in the 18 treated. Eight of the nine patients (89%) who had relapse entered continuous complete remission following salvage therapy. The overall 2-year disease-free survival in this case series is 98%. Retroperitoneal lymphadenectomy followed by compulsive follow-up and selective use of aggressive chemotherapy is an alternative to remission induction chemotherapy as primary treatment in clinical nonbulky Stage II nonseminomatous testis cancer, and to immediate adjuvant chemotherapy in all patients with resected Stage II disease.